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RECEIVED <br />FEB 2 5 2016 <br />Spill Bucket Testing Report Form 1?cft7md1FW;r* <br />This form is intended for use by contractors perform ng annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />4 CAf 11 IrV 1K1CnMRAArlr%u <br />Facility Name: Shelnesoro <br />Date of Testing: 01/26/16 <br />Facility Address: 35 N. Cherokee Ln. Lodi, CA 95240 <br />Facility contact: Grace Keller (209) 369-1525 <br />Date Local Agency Was Notified of Testing: 12/30/15 <br />Name of Local Agency inspector (if present during testing): Victoria McCartney <br />7 TCCTINV_ t f%KMnAr-rn® 1k100% vnewY.r <br />company Name: Service Station Systems <br />0 <br />Technician Conducting Test: Myke Brl gS <br />Credentials: ® CSLB Contractor ❑X ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br />License Number(s): License: 485184 ICC:8033115-UT <br />R SPI1 1 Pi lf_KCT TCC rlklt± lslrnoasArinu <br />Test Method Used: <br />® Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: Measuring Tape <br />Equipment Resolution:1116 in. <br />1 Fill Bucket <br />01 - Re u <br />2 Fill Bucket <br />02 - Prem <br />3 Fill Bucket 4 <br />03 - Diesel <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc,) <br />Bucket Installation Type: <br />❑X Direct Bury <br />❑ Contained in Sump <br />® Direct Bury <br />❑ Contained in Sump <br />® Direct Bury ❑ Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />Bucket Diameter. <br />14.00 in. <br />14.00 in. <br />14.00 in. <br />Bucket Depth: <br />13.00 in. <br />13.25 in. <br />13.00 in. <br />Wait time between applying <br />vacuumlwater and start of test: <br />10 min. <br />10 min. <br />10 min. <br />Test Start Time RI ): <br />10:00am <br />10:00am <br />10:00am <br />Initial Reading (Ri ): <br />12.50 in. <br />12.00 in. <br />12.50 in. <br />Test End Time (TF ): <br />11:00am <br />11:00am <br />11:00am <br />Final Reading {l ): <br />12.50 in. <br />12.00 in. <br />12.50 in. <br />Test Duration (TF - T i): <br />1.00 hr. <br />1.00 hr. <br />1.00 hr. <br />Change in Reading (RF - R, ): <br />0.000 in. <br />0.000 in. <br />0.000 in. <br />Pass/Fail Threshold or Criteria: ZERO LOSS ZERO LOSS ZERO LOSS <br />e".�t Rett s A . ,til alit I��d�+ ` 2, ,1r e]•jtr N%°`*G" i �' rt�Edo-% �ti 1� 6 illi �� <br />o, k . ®_,_ie$s ,i❑a1>>,a 1e lib8 , I'I FStI <br />Comments: Include information on repairs made prior to testing, and recommended follow-up for failed tests. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certffy that aft the nfonnation contained In this report is true, accurate and In full compliance wM legal requirements. <br />Technician's <br />Date:_01/26/16 <br />t State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />